24 Mar Conservative Management Could be a Reasonable Alternative to Renal Replacement Therapy in Select Patients
MedicalResearch.com Interview with:
Dr. Wouter R. Verberne
MedicalResearch.com: What is the background for this study?
Dr. Verberne: The number of older patients with End Stage Renal Disease (ESRD) is increasing worldwide. When ESRD is approaching, patients need to be advised on the renal replacement therapy (RRT) necessary to remove toxic products and fluid from the body when their own kidneys are no longer able to do so. ESRD can be treated with kidney transplantation, hemodialysis or peritoneal dialysis. With increasing technical possibilities and with the widespread availability of dialysis treatment, age no longer limits dialysis treatment.
It has been questioned whether older patients with ESRD, who often have multiple comorbidities, are likely to benefit from renal replacement therapy. Dialysis treatment comes with high treatment burden. Generally patients are treated in a dialysis facility 3 times per week, 3 to 4 hours per time. Patients with an anticipated poor prognosis on RRT may choose to forego dialysis and decide to be treated conservatively instead. Conservative management (CM) entails ongoing care with full medical treatment, including control of fluid and electrolyte balance and correcting anemia, and provision of appropriate palliative and end of life care.
Shared decision making has been recommended to come to a joint decision on renal replacement therapy by considering potential benefits and harms of all treatment options and the patient’s preferences. Data on outcomes, including survival and quality of life, are needed to foster the decision making. However, adequate survival data, specifically on older patients, are limited.
A number of studies, predominantly from the United Kingdom, have determined survival of older patients managed conservatively compared with renal replacement therapy. In these studies, the numbers of recruited patients are generally small, the studies are performed in heterogeneous study populations, and there is significant variability in starting points used in survival analyses. We performed the first Dutch study in a large series of older patients slowly approaching ESRD, enabling the use of several starting points in survival analyses. The aims of the study were to compare survival in patients with ESRD ages ≥ 70 years old choosing either conservative management or renal replacement therapy and determine predictors of survival.
MedicalResearch.com: What are the main findings?
Dr. Verberne: In this single-center observational study, there was no statistically significant survival advantage among patients ages ≥ 80 years old choosing renal replacement therapy over conservative therapy. Comorbidity was also associated with a lower survival advantage. This provides important information for decision making in older patients with ESRD. Conservative management could be a reasonable alternative to RRT in selected patients.
MedicalResearch.com: What should clinicians and patients take away from your report?
Dr. Verberne: We do NOT conclude that dialysis treatment should not be given to anybody > 80 years or with severe comorbidity. We show that the treatment is on average of little advantage regarding survival. Our next task is to predict who benefits and who does not. Until we are able to give a better prediction of the results of dialysis treatment at high age, we can merely suggest that conservative management is an option that should honestly be discussed when ESRD is approaching.
Most Important: We conclude that conservative management could be a reasonable alternative in older patients with ESRD. Comorbidity was associated with a lower survival advantage. This provides important information for decision making in older patients with ESRD. Further and larger studies are needed to determine which patients precisely benefit and which patients do not benefit from dialysis treatment. More work needs to be done to determine survival and other outcome data, like quality of life, that are needed to truly foster decision making.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Dr. Verberne: Further and larger studies are needed to determine which patients precisely benefit and which patients do not benefit from dialysis treatment. More work needs to be done to determine survival and other outcome data, like quality of life, that are needed to truly foster decision making.
MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.
Wouter R. Verberne, A.B.M. Tom Geers, Wilbert T. Jellema, Hieronymus H. Vincent, Johannes J.M. van Delden, and Willem Jan W. Bos
Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis
CJASN CJN.07510715; published ahead of print March 17, 2016,doi:10.2215/CJN.07510715
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